Dermatologic surgery “deals with the diagnosis and treatment of medically necessary and cosmetic conditions of the skin, hair, nails, veins, mucous membranes and adjacent tissues by various surgical, reconstructive, cosmetic and nonsurgical methods.”1 This depiction of dermatologic surgery from the American Society for Dermatologic Surgery continues with a description of the purpose of dermatologic surgery: “To repair and/or improve the function and cosmetic appearance of skin tissue.”1
Dermatologic surgery can be used to treat a multitude of skin conditions. Some of these are less serious and include acne, birthmarks, scars and more. This subset of dermatology can also be employed for more serious conditions like skin cancer. Dermatologic surgery procedures can be performed on the face for both benign and more serious issues, as well as aesthetic and medical concerns.
Here, 5 aspects of the facial muscles are discussed with regard to dermatologic surgery procedures.
Galea Aponeurotica
The galea aponeurotica is the strongest layer of the scalp. It consists of 2 layers of dense, fibrous fascia and connects the anterior and posterior bellies of the occipitofrontalis muscle. It is connected to the integument by dense fibrous bands called retinaculae that also form the support network for blood vessels. The forehead is an anatomical extension of the scalp, and greater mobility is achieved by excising through the frontalis muscle that is enveloped by 2 layers of the galea.2 The galea aponeurotica is connected to the pericranium by loose areolar connective tissue, resulting in a largely avascular space that is an optimal site for undermining of the scalp to occur.
This avascular space allows the aponeurosis to recruit mobility, carrying the hair bearing skin with it. The galea and the skin function as a unit and can move freely over the deeper layers of the scalp.3 The galea is substantially stronger than the overlying skin and will retain suture with less tearing if that suture is anchored securely deep throughout this fascia. See Figure 1.
Figure 1. Defect exposing the subgaleal space.
The Superficial Temporal Artery
The superficial temporal artery is one of the terminal branches of the external carotid artery when it bifurcates, with the other branch being the maxillary artery. The superficial temporal artery is one of the main arteries of the head and begins its path in the parotid gland, passing superiorly over the zygomatic process of the temporal bone. It then divides into 2 branches: the frontal branch and the parietal branch.
The frontal branch of the superficial temporal artery follows a tortuous path up and toward the forehead, supplying blood to the forehead and upper parts of the scalp. The frontal branch terminates by anastomosis through the supraorbital artery and frontal artery. The significance of locating and following the frontal branch of the superficial temporal artery is that it can be used as an anatomical landmark to locate and protect the temporal branch of the facial nerve during dermatologic surgery, a nerve that innervates the frontalis and orbicularis muscles and, if damaged, can cause eyebrow ptosis.4 The temporal branch of the facial nerve is the most vulnerable of any axial motor nerve and is most susceptible as it passes over the zygomatic arch and through the temporal fossa. Of note, temporary paralysis will routinely occur with wide infiltration of local anesthetic. Permanent paralysis occurs when the nerve is transected.5 See Figures 2-5.
Figure 2. Defect over the left temporal branch of the facial nerve and artery.
Figure 3. Defect over the right facial nerve and artery.
Figure 4. An example of eyebrow ptosis, occurring when the temporal branch of the facial nerve is transected.
Figure 5. An example of eyebrow ptosis, occurring when the temporal branch of the facial nerve is transected. Gold weight in right eyelid is visible.
Erb’s Point (CN XI at risk)
The accessory nerve (CN XI) must be taken into consideration during surgery on the neck. The accessory nerve courses across the posterior triangle of the neck in a superficial plane and emerges posterior to the sternocleidomastoid within centimeters of Erb’s point. Erb’s point is located in the posterior triangle of the neck behind the sternocleidomastoid and is the site of the lateral root of the brachial plexus, about 2-3 centimeters above the clavicle. Branches of suprascapular and subclavius nerves merge at Erb’s point, and it is also the location of emergence of the lesser occipital sensory nerve (which innervates the postauricular area), the greater auricular sensory nerve (which innervates the ear) and the transverse cervical nerve (which innervates the anterior neck).
Being aware of the location and significance of Erb’s point can prevent CN XI damage. CN XI innervates the trapezius muscle and can cause varying degrees of shoulder dysfunction if damaged, including (but not limited to) shoulder droop and winged scapula.6 The accessory nerve is less frequently encountered than the temporal branch of the facial nerve. See Figures 6 and 7.
Figure 6. Defect exposing Erb’s point on left side.
Figure 7. Smaller defect exposing Erb’s point on left side.
The SMAS
The muscles of facial expression have no bony attachments; they are anchored to fascia. The Superficial Muscular Aponeurontic System (SMAS) is the layer of fascia attached to facial skin by multiple fibrous extensions that pierce subcutaneous fat.7 The SMAS also surrounds and attaches to the deeper tissues and structures of the face and neck, including the platysma. If needed, the SMAS can be utilized to aid in the closure of a defect using a procedure called “SMAS Plication.” This procedure involves the SMAS being folded back on itself and secured, adding deep approximation and even eversion to a surgical defect.8 Once the SMAS is plicated, the overlying subcutis, dermis and epidermis can be more easily reapproximated with routine closures. See Figures 8 and 9.
Figure 8. Defect showing exposure of the SMAS.
Figure 9. An example of a closure where SMAS plication was utilized.
Cosmetic Subunit/Unit Principle
Dermatologic surgery closures are planned so that, ideally, they fall within the transitions of the cosmetic units of the face. For example, the scalp and forehead are individual cosmetic units, and the hairline is the junction line separating the 2 units. Other important junction lines of the face include the eyebrows, philtrum, alar crease, nasolabial fold, melolabial fold and labiomental crease.
Cosmetic units can be divided even further by subunits within the unit, and the distinction between subunits can be subtle and variable. Paying close attention to changes in color, texture and hair characteristics can be helpful in identifying different subunits. For example, the glabella is separated from the nasal dorsum, which is flanked by 2 lateral sidewalls, nasofacial sulcus, alar crease, the alae, the tip and the columella adjacent to the soft triangles.
If form and function are conserved, cosmetic interests should be taken into consideration when closing a defect. Being aware of junction lines between units and being able to see the separation of subunits will increase the quality of the closures. By placing suture lines on junction boundaries when closing a surgical wound, scar formation is optimized.9 In defects where a flap is required, using tissue from the same or adjacent cosmetic unit and taking care not to cross multiple units will result in the most aesthetically pleasing closure and scar. See Figures 10-13.
Figure 10. A defect confined to one cosmetic subunit.
Figure 11. A closure that is placed in a junction line between cosmetic subunits to decrease scar visibility.
Figure 12. A defect confined to one cosmetic subunit.
Figure 13. A closure that is placed in a junction line between cosmetic subunits to decrease scar visibility.
In addition, anatomical subunits are preferable in naming locations. “Dorsum” is far more specific than “nose.” Similarly, the ear can be divided in multiple subunits for description. In addition, naming a location by its underlying structures will avoid confusion among multiple biopsy sites. For example, the authors prefer “lower brachioradialis” rather than “forearm” or “left of T8” (thoracic vertebrae 8) rather than “back.”
Enhancing Outcomes
Dermatologic surgery can be performed for a number of medical and cosmetic indications on the face. By utilizing specific names and locations, optimal outcomes can be achieved.
Grace Brummer, BS, is clinical anatomic lab faculty, Brigham Young University.
Jordan Troxel, BS, is with Central Utah Clinic and Tufts University.
S. Ray Peterson, MD, FAAD, FACMS, is director cutaneous oncology, Central Utah Clinic.
Disclosure: None of the authors have any disclosures to report.
References
1. American Society for Dermatologic Surgery. What is dermatologic surgery? Available at: https://www.asds.net/asds-public.aspx. Accessed July 1, 2013.
2. Alam M, ed. Evidence-Based Procedural Dermatology. New York, NY: Springer; 2012:363.
3. Moore K. Clinically Oriented Anatomy. 2nd ed. Baltimore, MD: Williams & Wilkins; 1985:855.
4. Lei T, Xu DC, Gao JH, et al. Using the frontal branch of the superficial temporal artery as a landmark for locating the course of the temporal branch of the facial nerve during rhytidectomy: An anatomical study. Plast Reconstr Surg. 2005;116(2):623-629.
5. Nouri K. Complications in Dermatologic Surgery. Philadelphia, PA: Saunders Elsevier; 2008:16,65.
6. Walvekar RR. Accessory nerve injury. Medscape reference. Available at: https://emedicine.medscape.com/article/1298684-overview.
Accessed July 1, 2013.
7. Marrero GM, Eliezri YD. The use of the SMAS to close Mohs defects invading the parotid gland. Dermatol Surg. 1998;24(12):1335-1337.
8. Vidimos AT, Ammirati CT, Poblete-Lopez C. Dermatologic Surgery – Requisites in Dermatology. Philadelphia, PA: Saunders Elsevier; 2009.
9. Orengo I. Facial anatomy in cutaneous surgery: Cosmetic units and subunits. Medscape reference. Available at: https://emedicine.medscape.com/article/1127307-overview#aw2aab6b3. Accessed July 1, 2013.
Dermatologic surgery “deals with the diagnosis and treatment of medically necessary and cosmetic conditions of the skin, hair, nails, veins, mucous membranes and adjacent tissues by various surgical, reconstructive, cosmetic and nonsurgical methods.”1 This depiction of dermatologic surgery from the American Society for Dermatologic Surgery continues with a description of the purpose of dermatologic surgery: “To repair and/or improve the function and cosmetic appearance of skin tissue.”1
Dermatologic surgery can be used to treat a multitude of skin conditions. Some of these are less serious and include acne, birthmarks, scars and more. This subset of dermatology can also be employed for more serious conditions like skin cancer. Dermatologic surgery procedures can be performed on the face for both benign and more serious issues, as well as aesthetic and medical concerns.
Here, 5 aspects of the facial muscles are discussed with regard to dermatologic surgery procedures.
Galea Aponeurotica
The galea aponeurotica is the strongest layer of the scalp. It consists of 2 layers of dense, fibrous fascia and connects the anterior and posterior bellies of the occipitofrontalis muscle. It is connected to the integument by dense fibrous bands called retinaculae that also form the support network for blood vessels. The forehead is an anatomical extension of the scalp, and greater mobility is achieved by excising through the frontalis muscle that is enveloped by 2 layers of the galea.2 The galea aponeurotica is connected to the pericranium by loose areolar connective tissue, resulting in a largely avascular space that is an optimal site for undermining of the scalp to occur.
This avascular space allows the aponeurosis to recruit mobility, carrying the hair bearing skin with it. The galea and the skin function as a unit and can move freely over the deeper layers of the scalp.3 The galea is substantially stronger than the overlying skin and will retain suture with less tearing if that suture is anchored securely deep throughout this fascia. See Figure 1.
Figure 1. Defect exposing the subgaleal space.
The Superficial Temporal Artery
The superficial temporal artery is one of the terminal branches of the external carotid artery when it bifurcates, with the other branch being the maxillary artery. The superficial temporal artery is one of the main arteries of the head and begins its path in the parotid gland, passing superiorly over the zygomatic process of the temporal bone. It then divides into 2 branches: the frontal branch and the parietal branch.
The frontal branch of the superficial temporal artery follows a tortuous path up and toward the forehead, supplying blood to the forehead and upper parts of the scalp. The frontal branch terminates by anastomosis through the supraorbital artery and frontal artery. The significance of locating and following the frontal branch of the superficial temporal artery is that it can be used as an anatomical landmark to locate and protect the temporal branch of the facial nerve during dermatologic surgery, a nerve that innervates the frontalis and orbicularis muscles and, if damaged, can cause eyebrow ptosis.4 The temporal branch of the facial nerve is the most vulnerable of any axial motor nerve and is most susceptible as it passes over the zygomatic arch and through the temporal fossa. Of note, temporary paralysis will routinely occur with wide infiltration of local anesthetic. Permanent paralysis occurs when the nerve is transected.5 See Figures 2-5.
Figure 2. Defect over the left temporal branch of the facial nerve and artery.
Figure 3. Defect over the right facial nerve and artery.
Figure 4. An example of eyebrow ptosis, occurring when the temporal branch of the facial nerve is transected.
Figure 5. An example of eyebrow ptosis, occurring when the temporal branch of the facial nerve is transected. Gold weight in right eyelid is visible.
Erb’s Point (CN XI at risk)
The accessory nerve (CN XI) must be taken into consideration during surgery on the neck. The accessory nerve courses across the posterior triangle of the neck in a superficial plane and emerges posterior to the sternocleidomastoid within centimeters of Erb’s point. Erb’s point is located in the posterior triangle of the neck behind the sternocleidomastoid and is the site of the lateral root of the brachial plexus, about 2-3 centimeters above the clavicle. Branches of suprascapular and subclavius nerves merge at Erb’s point, and it is also the location of emergence of the lesser occipital sensory nerve (which innervates the postauricular area), the greater auricular sensory nerve (which innervates the ear) and the transverse cervical nerve (which innervates the anterior neck).
Being aware of the location and significance of Erb’s point can prevent CN XI damage. CN XI innervates the trapezius muscle and can cause varying degrees of shoulder dysfunction if damaged, including (but not limited to) shoulder droop and winged scapula.6 The accessory nerve is less frequently encountered than the temporal branch of the facial nerve. See Figures 6 and 7.
Figure 6. Defect exposing Erb’s point on left side.
Figure 7. Smaller defect exposing Erb’s point on left side.
The SMAS
The muscles of facial expression have no bony attachments; they are anchored to fascia. The Superficial Muscular Aponeurontic System (SMAS) is the layer of fascia attached to facial skin by multiple fibrous extensions that pierce subcutaneous fat.7 The SMAS also surrounds and attaches to the deeper tissues and structures of the face and neck, including the platysma. If needed, the SMAS can be utilized to aid in the closure of a defect using a procedure called “SMAS Plication.” This procedure involves the SMAS being folded back on itself and secured, adding deep approximation and even eversion to a surgical defect.8 Once the SMAS is plicated, the overlying subcutis, dermis and epidermis can be more easily reapproximated with routine closures. See Figures 8 and 9.
Figure 8. Defect showing exposure of the SMAS.
Figure 9. An example of a closure where SMAS plication was utilized.
Cosmetic Subunit/Unit Principle
Dermatologic surgery closures are planned so that, ideally, they fall within the transitions of the cosmetic units of the face. For example, the scalp and forehead are individual cosmetic units, and the hairline is the junction line separating the 2 units. Other important junction lines of the face include the eyebrows, philtrum, alar crease, nasolabial fold, melolabial fold and labiomental crease.
Cosmetic units can be divided even further by subunits within the unit, and the distinction between subunits can be subtle and variable. Paying close attention to changes in color, texture and hair characteristics can be helpful in identifying different subunits. For example, the glabella is separated from the nasal dorsum, which is flanked by 2 lateral sidewalls, nasofacial sulcus, alar crease, the alae, the tip and the columella adjacent to the soft triangles.
If form and function are conserved, cosmetic interests should be taken into consideration when closing a defect. Being aware of junction lines between units and being able to see the separation of subunits will increase the quality of the closures. By placing suture lines on junction boundaries when closing a surgical wound, scar formation is optimized.9 In defects where a flap is required, using tissue from the same or adjacent cosmetic unit and taking care not to cross multiple units will result in the most aesthetically pleasing closure and scar. See Figures 10-13.
Figure 10. A defect confined to one cosmetic subunit.
Figure 11. A closure that is placed in a junction line between cosmetic subunits to decrease scar visibility.
Figure 12. A defect confined to one cosmetic subunit.
Figure 13. A closure that is placed in a junction line between cosmetic subunits to decrease scar visibility.
In addition, anatomical subunits are preferable in naming locations. “Dorsum” is far more specific than “nose.” Similarly, the ear can be divided in multiple subunits for description. In addition, naming a location by its underlying structures will avoid confusion among multiple biopsy sites. For example, the authors prefer “lower brachioradialis” rather than “forearm” or “left of T8” (thoracic vertebrae 8) rather than “back.”
Enhancing Outcomes
Dermatologic surgery can be performed for a number of medical and cosmetic indications on the face. By utilizing specific names and locations, optimal outcomes can be achieved.
Grace Brummer, BS, is clinical anatomic lab faculty, Brigham Young University.
Jordan Troxel, BS, is with Central Utah Clinic and Tufts University.
S. Ray Peterson, MD, FAAD, FACMS, is director cutaneous oncology, Central Utah Clinic.
Disclosure: None of the authors have any disclosures to report.
References
1. American Society for Dermatologic Surgery. What is dermatologic surgery? Available at: https://www.asds.net/asds-public.aspx. Accessed July 1, 2013.
2. Alam M, ed. Evidence-Based Procedural Dermatology. New York, NY: Springer; 2012:363.
3. Moore K. Clinically Oriented Anatomy. 2nd ed. Baltimore, MD: Williams & Wilkins; 1985:855.
4. Lei T, Xu DC, Gao JH, et al. Using the frontal branch of the superficial temporal artery as a landmark for locating the course of the temporal branch of the facial nerve during rhytidectomy: An anatomical study. Plast Reconstr Surg. 2005;116(2):623-629.
5. Nouri K. Complications in Dermatologic Surgery. Philadelphia, PA: Saunders Elsevier; 2008:16,65.
6. Walvekar RR. Accessory nerve injury. Medscape reference. Available at: https://emedicine.medscape.com/article/1298684-overview.
Accessed July 1, 2013.
7. Marrero GM, Eliezri YD. The use of the SMAS to close Mohs defects invading the parotid gland. Dermatol Surg. 1998;24(12):1335-1337.
8. Vidimos AT, Ammirati CT, Poblete-Lopez C. Dermatologic Surgery – Requisites in Dermatology. Philadelphia, PA: Saunders Elsevier; 2009.
9. Orengo I. Facial anatomy in cutaneous surgery: Cosmetic units and subunits. Medscape reference. Available at: https://emedicine.medscape.com/article/1127307-overview#aw2aab6b3. Accessed July 1, 2013.
Dermatologic surgery “deals with the diagnosis and treatment of medically necessary and cosmetic conditions of the skin, hair, nails, veins, mucous membranes and adjacent tissues by various surgical, reconstructive, cosmetic and nonsurgical methods.”1 This depiction of dermatologic surgery from the American Society for Dermatologic Surgery continues with a description of the purpose of dermatologic surgery: “To repair and/or improve the function and cosmetic appearance of skin tissue.”1
Dermatologic surgery can be used to treat a multitude of skin conditions. Some of these are less serious and include acne, birthmarks, scars and more. This subset of dermatology can also be employed for more serious conditions like skin cancer. Dermatologic surgery procedures can be performed on the face for both benign and more serious issues, as well as aesthetic and medical concerns.
Here, 5 aspects of the facial muscles are discussed with regard to dermatologic surgery procedures.
Galea Aponeurotica
The galea aponeurotica is the strongest layer of the scalp. It consists of 2 layers of dense, fibrous fascia and connects the anterior and posterior bellies of the occipitofrontalis muscle. It is connected to the integument by dense fibrous bands called retinaculae that also form the support network for blood vessels. The forehead is an anatomical extension of the scalp, and greater mobility is achieved by excising through the frontalis muscle that is enveloped by 2 layers of the galea.2 The galea aponeurotica is connected to the pericranium by loose areolar connective tissue, resulting in a largely avascular space that is an optimal site for undermining of the scalp to occur.
This avascular space allows the aponeurosis to recruit mobility, carrying the hair bearing skin with it. The galea and the skin function as a unit and can move freely over the deeper layers of the scalp.3 The galea is substantially stronger than the overlying skin and will retain suture with less tearing if that suture is anchored securely deep throughout this fascia. See Figure 1.
Figure 1. Defect exposing the subgaleal space.
The Superficial Temporal Artery
The superficial temporal artery is one of the terminal branches of the external carotid artery when it bifurcates, with the other branch being the maxillary artery. The superficial temporal artery is one of the main arteries of the head and begins its path in the parotid gland, passing superiorly over the zygomatic process of the temporal bone. It then divides into 2 branches: the frontal branch and the parietal branch.
The frontal branch of the superficial temporal artery follows a tortuous path up and toward the forehead, supplying blood to the forehead and upper parts of the scalp. The frontal branch terminates by anastomosis through the supraorbital artery and frontal artery. The significance of locating and following the frontal branch of the superficial temporal artery is that it can be used as an anatomical landmark to locate and protect the temporal branch of the facial nerve during dermatologic surgery, a nerve that innervates the frontalis and orbicularis muscles and, if damaged, can cause eyebrow ptosis.4 The temporal branch of the facial nerve is the most vulnerable of any axial motor nerve and is most susceptible as it passes over the zygomatic arch and through the temporal fossa. Of note, temporary paralysis will routinely occur with wide infiltration of local anesthetic. Permanent paralysis occurs when the nerve is transected.5 See Figures 2-5.
Figure 2. Defect over the left temporal branch of the facial nerve and artery.
Figure 3. Defect over the right facial nerve and artery.
Figure 4. An example of eyebrow ptosis, occurring when the temporal branch of the facial nerve is transected.
Figure 5. An example of eyebrow ptosis, occurring when the temporal branch of the facial nerve is transected. Gold weight in right eyelid is visible.
Erb’s Point (CN XI at risk)
The accessory nerve (CN XI) must be taken into consideration during surgery on the neck. The accessory nerve courses across the posterior triangle of the neck in a superficial plane and emerges posterior to the sternocleidomastoid within centimeters of Erb’s point. Erb’s point is located in the posterior triangle of the neck behind the sternocleidomastoid and is the site of the lateral root of the brachial plexus, about 2-3 centimeters above the clavicle. Branches of suprascapular and subclavius nerves merge at Erb’s point, and it is also the location of emergence of the lesser occipital sensory nerve (which innervates the postauricular area), the greater auricular sensory nerve (which innervates the ear) and the transverse cervical nerve (which innervates the anterior neck).
Being aware of the location and significance of Erb’s point can prevent CN XI damage. CN XI innervates the trapezius muscle and can cause varying degrees of shoulder dysfunction if damaged, including (but not limited to) shoulder droop and winged scapula.6 The accessory nerve is less frequently encountered than the temporal branch of the facial nerve. See Figures 6 and 7.
Figure 6. Defect exposing Erb’s point on left side.
Figure 7. Smaller defect exposing Erb’s point on left side.
The SMAS
The muscles of facial expression have no bony attachments; they are anchored to fascia. The Superficial Muscular Aponeurontic System (SMAS) is the layer of fascia attached to facial skin by multiple fibrous extensions that pierce subcutaneous fat.7 The SMAS also surrounds and attaches to the deeper tissues and structures of the face and neck, including the platysma. If needed, the SMAS can be utilized to aid in the closure of a defect using a procedure called “SMAS Plication.” This procedure involves the SMAS being folded back on itself and secured, adding deep approximation and even eversion to a surgical defect.8 Once the SMAS is plicated, the overlying subcutis, dermis and epidermis can be more easily reapproximated with routine closures. See Figures 8 and 9.
Figure 8. Defect showing exposure of the SMAS.
Figure 9. An example of a closure where SMAS plication was utilized.
Cosmetic Subunit/Unit Principle
Dermatologic surgery closures are planned so that, ideally, they fall within the transitions of the cosmetic units of the face. For example, the scalp and forehead are individual cosmetic units, and the hairline is the junction line separating the 2 units. Other important junction lines of the face include the eyebrows, philtrum, alar crease, nasolabial fold, melolabial fold and labiomental crease.
Cosmetic units can be divided even further by subunits within the unit, and the distinction between subunits can be subtle and variable. Paying close attention to changes in color, texture and hair characteristics can be helpful in identifying different subunits. For example, the glabella is separated from the nasal dorsum, which is flanked by 2 lateral sidewalls, nasofacial sulcus, alar crease, the alae, the tip and the columella adjacent to the soft triangles.
If form and function are conserved, cosmetic interests should be taken into consideration when closing a defect. Being aware of junction lines between units and being able to see the separation of subunits will increase the quality of the closures. By placing suture lines on junction boundaries when closing a surgical wound, scar formation is optimized.9 In defects where a flap is required, using tissue from the same or adjacent cosmetic unit and taking care not to cross multiple units will result in the most aesthetically pleasing closure and scar. See Figures 10-13.
Figure 10. A defect confined to one cosmetic subunit.
Figure 11. A closure that is placed in a junction line between cosmetic subunits to decrease scar visibility.
Figure 12. A defect confined to one cosmetic subunit.
Figure 13. A closure that is placed in a junction line between cosmetic subunits to decrease scar visibility.
In addition, anatomical subunits are preferable in naming locations. “Dorsum” is far more specific than “nose.” Similarly, the ear can be divided in multiple subunits for description. In addition, naming a location by its underlying structures will avoid confusion among multiple biopsy sites. For example, the authors prefer “lower brachioradialis” rather than “forearm” or “left of T8” (thoracic vertebrae 8) rather than “back.”
Enhancing Outcomes
Dermatologic surgery can be performed for a number of medical and cosmetic indications on the face. By utilizing specific names and locations, optimal outcomes can be achieved.
Grace Brummer, BS, is clinical anatomic lab faculty, Brigham Young University.
Jordan Troxel, BS, is with Central Utah Clinic and Tufts University.
S. Ray Peterson, MD, FAAD, FACMS, is director cutaneous oncology, Central Utah Clinic.
Disclosure: None of the authors have any disclosures to report.
References
1. American Society for Dermatologic Surgery. What is dermatologic surgery? Available at: https://www.asds.net/asds-public.aspx. Accessed July 1, 2013.
2. Alam M, ed. Evidence-Based Procedural Dermatology. New York, NY: Springer; 2012:363.
3. Moore K. Clinically Oriented Anatomy. 2nd ed. Baltimore, MD: Williams & Wilkins; 1985:855.
4. Lei T, Xu DC, Gao JH, et al. Using the frontal branch of the superficial temporal artery as a landmark for locating the course of the temporal branch of the facial nerve during rhytidectomy: An anatomical study. Plast Reconstr Surg. 2005;116(2):623-629.
5. Nouri K. Complications in Dermatologic Surgery. Philadelphia, PA: Saunders Elsevier; 2008:16,65.
6. Walvekar RR. Accessory nerve injury. Medscape reference. Available at: https://emedicine.medscape.com/article/1298684-overview.
Accessed July 1, 2013.
7. Marrero GM, Eliezri YD. The use of the SMAS to close Mohs defects invading the parotid gland. Dermatol Surg. 1998;24(12):1335-1337.
8. Vidimos AT, Ammirati CT, Poblete-Lopez C. Dermatologic Surgery – Requisites in Dermatology. Philadelphia, PA: Saunders Elsevier; 2009.
9. Orengo I. Facial anatomy in cutaneous surgery: Cosmetic units and subunits. Medscape reference. Available at: https://emedicine.medscape.com/article/1127307-overview#aw2aab6b3. Accessed July 1, 2013.
